Cycle 1
Health 2026-01-14 · Fire 2026-01-14
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Valparaiso, IN
Avalon Springs Health Campus
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2400 Silhavy Road, Valparaiso, IN
(219) 462-1778
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
55
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2012-04-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.27
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,609
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 19.41% · Performance 20.23% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Healthcare-associated infections
4.69
Baseline 6.22% · Performance 6.43% · Measure score 4.69 · Achievement 4.69 · Improvement 0
Total nurse turnover
5.61
Baseline 40.00% · Performance 40.74% · Measure score 5.61 · Achievement 5.61 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.41% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 443 · Observed rate 11.96% · Lower 95% interval 9.54% |
| Discharge to community | 63.05% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 396 · Observed rate 60.35% · Lower 95% interval 58.56% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 293 · Denominator 293 |
| Falls with major injury | 0.34% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 293 |
| Discharge self-care score | 72.58% |
53.69%
18.9 pts better
|
Numerator 180 · Denominator 248 |
| Discharge mobility score | 81.05% |
50.94%
30.1 pts better
|
Numerator 201 · Denominator 248 |
| Pressure ulcers or injuries, new or worsened | 2.05% |
2.29%
0.2 pts better
|
Numerator 6 · Denominator 293 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 279 · Observed rate 5.38% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 112 |
| Staff flu vaccination coverage | 51.39% |
42%
9.4 pts better
|
Numerator 74 · Denominator 144 |
| Discharge function score | 76.21% |
56.45%
19.8 pts better
|
Numerator 189 · Denominator 248 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 99.49% |
96.28%
3.2 pts better
|
Numerator 197 · Denominator 198 |
| Resident COVID-19 vaccinations up to date | 30.52% |
25.2%
5.3 pts better
|
Numerator 47 · Denominator 154 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.9 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
93.6%
0.2 pts worse
|
93.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 96.8% · Q3 96.7% · Q4 100.0% · 4Q avg 93.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 6.7% · Q4 6.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
24.6%
23.7 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.6%
1.6 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 7.7% · Q4 4.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
23.5%
7.2 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 20.0% · Q3 15.4% · Q4 14.3% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.8%
14.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.6% |
13.3%
2.7 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
11.7%
6.7 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.2% · Q3 0.0% · Q4 7.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.2%
0.5 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
24.2%
4.8 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 18.5% · Q3 20.5% · Q4 22.8% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.1%
1.8 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.0% · Q3 2.6% · Q4 5.2% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
81.6%
16.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 98.4% · Q3 99.5% · Q4 98.9% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
10.5%
3.4 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.1% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
79.0%
16.7 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
22.4%
1.4 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 20.5% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-26 · Fire 2024-11-26
16 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-12-04 · Fire 2023-12-04
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
F · Potential for more than minimal harm
2026-01-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
F · Potential for more than minimal harm
2026-01-14
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Not marked corrected
E · Potential for more than minimal harm
2026-01-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2026-01-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
F · Potential for more than minimal harm
2024-11-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-13
F · Potential for more than minimal harm
2023-12-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-07
F · Potential for more than minimal harm
2023-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-07
E · Potential for more than minimal harm
2023-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-05
D · Potential for more than minimal harm
2025-10-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-24
D · Potential for more than minimal harm
2024-11-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-06-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-01-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-04
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-29
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Barney, Leigh
General Partnership Interest · Individual
Bond, Maria
Corporate Director · Individual
Clark, Timothy
Corporate Director · Individual
Daugherty, Joshua
Corporate Director · Individual
Davis, David
General Partnership Interest · Individual
Felker, Dean
Corporate Director · Individual
Joyner, Sara
Corporate Director · Individual
Long, Steven
Operational/Managerial Control · Individual
Long, Steven
Corporate Officer · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Mirochna, Michael
Operational/Managerial Control · Individual
Trilogy Healthcare Of Greenfield, LLC
Operational/Managerial Control · Organization
Trilogy Healthcare Of Porter, LLC
Operational/Managerial Control · Organization
Wilson, Roy
Corporate Director · Individual
Wray, Crystal
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of The Willows
Valparaiso, IN
1-star overall rating with 1-star inspections with $14,886 in total fines with 16 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
#2
Valparaiso Care & Rehabilitation
Valparaiso, IN
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Brickyard Healthcare - Valparaiso Care Center
Valparaiso, IN
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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